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MEAL DAY 1 DAY 2 DAY 3 DAY 4 DAY 5 DAY 6 DAY 7

Time:
Morning
Meal

Snack:
Time:
Noon
Meal

Snack
Time:
Evening
Meal

Snack
Additional Foods &
Beverages
Water (cups/day)
Fats/Oils Used
Condiments
Salt, Sugar, Spices, etc.
Supplements Taken
Time:

Type of Exercise
Exercise Duration

Pulse‐before/during / / / / / / /
Relaxation
Name: __________________________
DIET/ACTIVITY REPORT: Week #: _________________________________
Please take time to complete the following survey carefully and accurately. List in detail the quantity and the exact nature of all foods and beverages consumed (i.e.
frozen, canned, etc.). Please mention if the foods were raw or cooked. Be sure to list any condiments used (i.e. mayonnaise, margarine, relish, etc.). Please complete
the exercise portion at the bottom as well, listing the type of exercise, its duration and your pulse before and during exercising. Also record any periods of
relaxation/meditation.